Most/all questions on this form are considered required, meaning you will not be able to move forward in the School Evaluation Form if you do not answer a question.  If you do not feel a question relates to your student or you are not comfortable answering the question, please put "N/A" if it is a free response question, or select "No," or "None," if it is a check box/radio button question.  This form will become part of the patient's file and parents/guardians may request a copy for themselves.

Selective Mutism School Evaluation Form

Save & Return

This form will take about 10 minutes to complete. You have the option to save your progress and complete this form later by creating an account.

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Type of school: *
 
Student's academic performance is: *
Does the student typically perform school work in a timely and efficient manner? *
Does the student often have difficulty initiating tasks (starting work promptly)? *
Does the student often hesitate with school work? *
Does the student receive formal accommodations in the school setting? *
If yes, what type of accommodation plan does the student have? *
 
 Copyright © 2013 Dr. Elisa Shipon-Blum and Selective Mutism, Anxiety, & Related Disorders Treatment Center, Inc. (SMart Center) – www.selectivemutismcenter.org.  215-887-5748 
All rights reserved.
This material is part of Dr. Elisa Shipon-Blum’s Social Communication Anxiety Treatment® (S-CAT)® and is used under license.